Supplemental Form for Breathwork Coaching & Calm & Relax Coaching

Name

Date Of Birth

Your Age

Address

Phone Number

Mobile Number

Best Time To Call

Why do you feel you want to try Breathwork Coaching?

What benefits are you hoping for?

Why do you feel you need Calm & Relax Coaching?

What benefits are you hoping for?

What health issues do you have at the moment that you want to tell me about?

What medical tests have you had in relation to the reason for coaching? What were the results?

Have you mentioned to your consultant or GP that you are having coaching?

Yes No

Are you on antidepressants? If so which ones and how long have you been taking them for?

Disclaimer: I accept that the information provided above is a true and accurate reflection of my state of health and will tell the therapist if there are any changes to the above information. Information is destroyed after 8years in line with insurance guidelines and GDPR 2018.

Get In Touch

Paradise Clinic
Corner, High St & Paradise Rd
Kemnay
Aberdeenshire
AB51 5NB

Mobile: 07896 047 660
drjones@paradiseclinic.co.uk

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ADDRESS:
Paradise Clinic
Corner, High St & Paradise Rd
Kemnay
Aberdeenshire
AB51 5NB

CONTACT PHONE:
07896 047 660

E-MAIL ADDRESS:
drjones@paradiseclinic.co.uk

Supplemental Form for Breathwork Coaching & Calm & Relax Coaching

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